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Perception, Reality and Health Insurance: Uninsured as Likely as Insured to Perceive Need for Care but Half as Likely to Get Care

Issue Brief No. 100October 2005
Jack Hadley, Peter J. Cunningham

While considerable research shows that uninsured people are less likely
to seek and receive medical care, some contend that the uninsured are uninsured
by choice and can obtain care when needed. A new study by the Center for Studying
Health System Change (HSC), however, undercuts the validity of this contention,
finding that there is no difference between insured and uninsured peoples perception
of the need to see a medical provider when they experience a serious new symptom.
However, among people who believed that they needed medical care, the uninsured
were less than half as likely to see or talk to a doctor, indicating that lack
of insurance is a major barrier to uninsured people getting needed medical care.

Uninsured by Choice?

esearch has shown that early detection and treatment of
medical problems can lead to better clinical outcomes and improved health.1
While considerable research indicates that health insurance encourages people
to seek timely care,2 some contend that the uninsured are
uninsured by choice and can obtain care when needed.3 Although
this contention has several dimensions, two key elements include:

The uninsured are less likely to perceive a need for care, either because they are healthier or, if they do become sick, they have different attitudes or preferences that make them less likely to seek care.

When the uninsured do get sick and need care, they are able to get care from safety net providers or by paying out of pocket.

HSCs 2003 nationally representative Household Survey asked people 18 and older
whether they had recently experienced a new occurrence of any of 15 symptoms—such
as shortness of breath, chest pain, persistent headache or loss of consciousness—identified
by a physician panel as either potentially life threatening or having a significant
impact on quality of life if not treated4 (see Data
Source and Table 1 for a complete list of symptoms).

The survey found that the uninsured were significantly more likely—23.2 percent of the uninsured compared with 18.9 percent of the insured—to report the recent onset of at least one of these symptoms.

Among those with a new symptom, there was no difference between insured and
uninsured peoples perception of the need to see a medical provider when they
experienced any of the 15 new symptoms or conditions (see Figure
1 and Table 2). Overall, about 58 percent of the people
with a new symptom or condition believed that they needed to see or talk to
a medical provider. However, even with similar conditions and similar severity
levels, uninsured people were much less likely than the insured to obtain medical
care in response to the new symptom. Among those who believed that they needed
to seek care, 82 percent of the insured saw or talked to a medical provider,
compared with 37 percent of the uninsured.

Differences in perceived need for care also are sometimes used to explain differences in access and use of services among whites and minorities; higher-income and lower-income people; and people with limited education. However, the findings show that there are minimal differences in the perceived need for care for these 15 symptoms by race/ethnicity, income or education. Racial and ethnic minorities, lower-income people, and people with less-than-college education have the same perceptions of when care is needed as whites, higher-income people, and people with college educations.

Table 2
Percentage of Nonelderly1 Adults Who Thought Care Was Needed and Who Saw
or Talked to a Doctor, by Various Characteristics

Thought Care Needed

Saw or Talked to a Doctor, Given Care Thought Needed

All Nonelderly Adults

57.9%

72.5%

Insurance Coverage

Uninsured (R)

55.8

36.6

Insured

58.5

82.1*

Usual Source of Care

No Usual Source of Care
(R)

49.7

47.4

Usual Source, No Regular
Doctor

56.2

69.4*

Usual Source, Regular
Doctor

60.8#

79.0*

Age

18-44 (R)

54.6

67.9

45 641

65.2#

78.7

Gender

Male (R)

51.4

67.9

Female

61.8*

74.8

Race and Ethnicity

White, non-Hispanic (R)

58.2

80.6

African-American

59.2

64.7#

Hispanic

60.2

46.3*

Health Status

Excellent, Very Good (R)

50.9

80.6

Good

60.9#

72.6

Fair/Poor

69.4*

58.6*

Education

Less than High School
(R)

54.2

49.9

High School Graduate

55.4

70.6*

College Graduate

66.4

88.9*

Income

Less than 200% FPL (R)

56.3

55.0

200-400% FPL

55.1

72.3*

400+ FPL

61.8

87.8*

1 Includes 40 people over age 65 without
Medicare coverage.
* Significantly different from reference group (R) a p < .01.
# Significantly different from reference group (R) a p < .05.Source: Community Tracking Study Household Survey, 2003

Symptom Severity Drives Perception of Care Need

eoples perception that care is needed after the onset of a new symptom increases as general health status worsens and activity limitation related to the symptom increases. Overall, uninsured and insured people who reported any of the 15 new symptoms were equally likely to report experiencing an activity limitation because of the symptom. People who said that they did not need to seek care were about half as likely to say they experienced an activity limitation—27 percent vs. 57 percent of people who believed they needed care.

Many socio-demographic factors that influence medical care use, including minority
race or ethnicity, poor general health status, low education and low income,
are associated with lack of insurance. But after accounting for socio-demographic
differences through statistical analysis,5 the uninsured
were still less than one-third as likely to actually see or talk to a doctor
(see Supplementary Table 1).

Implications

hese findings indicate that lack of health insurance—and
the resulting limits on access to care—is the main reason for differences in
the receipt of medical care between insured and uninsured people with serious
symptoms. This analysis both reinforces and extends prior research showing that
the uninsured are much less likely to receive needed medical care, even for
symptoms that can have serious health consequences if not treated.6
Finding that uninsured people are much less likely to receive needed medical
care for conditions that can have serious health consequences is consistent
with a substantial body of research that indicates the uninsured have poorer
health outcomes than the insured.7 Moreover, the findings
contradict contentions that differences in use of services between the insured
and the uninsured, between whites and racial/ethnic minorities, or between higher-
and lower-income people are a result of differences in perceptions about when
care is needed.

We estimated multivariate regression models to control for the specific symptoms reported, age, gender, race and ethnicity, self-reported health status, education, income, when the symptom first occurred within the last three months, whether it is associated with pregnancy, and indicators of care-seeking behavior.

Data Source

The data used in this analysis are from a special Symptom Response Module
(SRM) included in the 2003 HSC Community Tracking Study (CTS) Household Survey.
The CTS is a nationally representative telephone survey supplemented by in-person
interviews to include people without telephones. Approximately 47,000 people
were interviewed in 2003, and the response rate was 57 percent. The SRM is based
on an instrument developed by researchers for use in The Robert Wood Johnson
Foundations National Access to Care Survey.

The SRM collected information from a subset of respondents: all uninsured
adults (18 and older), all elderly people (65 and older), and a one-sixth random
sample of insured, nonelderly adults (18-64 years old). (CTS sampling weights
were adjusted for insured, nonelderly cases to reflect the additional random
sampling.) A total of 16,266 people were screened for the SRM and 3,299 respondents
(weighted 19.8%) indicated that they had experienced at least one new symptom
within the last three months. This analysis is limited to 1,939 adults who did
not have any Medicare coverage (1,024 uninsured and 913 insured).

The SRM asked respondents whether they had experienced a new occurrence
(within the last three months) of any of 15 symptoms that were identified by
a panel of physicians as either serious, i.e., potentially life threatening
if not treated, or morbid, i.e., not life threatening but having a significant
impact on quality of life. One serious symptom, or one morbid symptom if the
person had no serious symptoms, was randomly selected for a set of follow-up
questions about care-seeking behavior and activity limitations. (see Table 1
for the distribution of these symptoms). Respondents were then asked whether
they had seen or talked to a doctor or other health professional about this
problem. If they reported that they had not seen or talked to a doctor or other
health professional, they were asked if they thought that they . needed to contact
a doctor or other health professional about this problem. All respondents were
asked whether the problem limited their ability to do any of their usual activities
and, if so, for how many days they were limited in their ability to do any of
their usual activities.